Health inspection·June 1, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report an Injury of Unknown Origin timely for one (R4) resident out of three residents reviewed for Injuries of Unknown Origin in a sample list of seven residents. Findings include: R4's undated Face Sheet documents medical diagnoses as Dementia without behaviors, Diabetes Mellitus Type II, Peripheral Vascular Disease (PVD), Heart Failure, Cardiac Arrhythmia's, and bilateral hearing loss. R4's Minimum Data Set (MDS) dated [DATE] documents R4 as severely cognitively impaired. This same MDS documents R4 requires set up assistance for eating, supervision for oral hygiene, bed mobility, moderate assistance for personal hygiene, dressing, bathing, toileting, and transfers. R4's Notification to Physician dated 5/24/25 documents R4 was observed to have a 31.0 centimeter (cm) wide by 7.0 cm deep dark purple/pink bruise to Left Lower Abdomen. This same report documents (R4) is unable to say what happened. No fall or injury noted to area. R4's Initial Report to the State Agency dated 5/28/25 documents R4 had bruising to her abdomen. R4's Incident Investigation dated 5/28/25 documents V15 CNA first observed R4's abdominal bruise on 5/24/25 and reported this to V16 LPN. On 5/31/25 at 3:30 PM V15 Certified Nurse Aide (CNA) stated V15 first observed R4's abdominal bruise at 5:30 AM on 5/24/25. V15 CNA stated R4's bruise was 'deep, dark purple and black colored from (R4's) belly button to her Left back'. V15 CNA stated she immediately reported R4's bruise to V16 Licensed Practical Nurse (LPN) who told V2 Director of Nursing (DON). On 5/31/25 at 8:45 AM V2 Director of Nursing (DON) stated V21 Registered Nurse (RN) called V2 at 8:00 AM on 5/24/25 to report that R4 had a large bruise on her Left Lower Quadrant (LLQ). V2 DON stated she reported R4's large dark purple abdominal bruise to V1 on 5/24/25. On 6/1/25 at 1:15 PM V1 Administrator stated R4's abdominal bruise should have been reported to the State Agency on 5/24/25. V1 stated she thought there was an origin for R4's bruise and stated R4 met the criteria for her bruise to be considered an Injury of Unknown Origin so it should have been reported immediately. Page 1 of 4 145469 145469 06/01/2025 The Haven of Paris 1011 North Main Street Paris, IL 61944

F 0609 Level of Harm - Minimal harm or potential for actual harm The facility policy titled Abuse Policy and Procedures revised 9/26/2022 documents an initial report to the Stage Agency shall be made immediately after the resident has been assessed. The initial report shall include the name of the resident allegedly harmed, when the allegation was received, the time and date of the alleged incident, who was notified and when and the steps the facility has taken and a copy of this report shall be maintained. Residents Affected - Few 145469 Page 2 of 4 145469 06/01/2025 The Haven of Paris 1011 North Main Street Paris, IL 61944

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to complete a thorough investigation of an Injury of Unknown Origin for one (R4) resident out of three residents reviewed for Injuries of Unknown Origin in a sample list of seven residents. Residents Affected - Few Findings include: R4's undated Face Sheet documents medical diagnoses as Dementia without behaviors, Diabetes Mellitus Type II, Peripheral Vascular Disease (PVD), Heart Failure, Cardiac Arrhythmia's and bilateral hearing loss. R4's Minimum Data Set (MDS) dated [DATE] documents R4 as severely cognitively impaired. This same MDS documents R4 requires set up assistance for eating, supervision for oral hygiene, bed mobility, moderate assistance for personal hygiene, dressing, bathing, toileting, and transfers. R4's Medication Administration Record (MAR) dated May 2025 documents R4 was administered Insulin subcutaneously in her Left Lower Quadrant (LLQ) six times out of the last 30 administrations. The other injection sites included Right Lower Quadrant (RLQ) and bilateral upper arms. R4's Shower Sheet dated 5/23/25 does not document any bruising to R4's abdominal area. R4's Notification to Physician dated 5/24/25 documents R4 was observed to have a 31.0 centimeter (cm) wide by 7.0 cm deep dark purple/pink bruise to Left Lower Abdomen. This same report documents (R4) is unable to say what happened. No fall or injury noted to area. On 5/31/25 at 8:45 AM V2 Director of Nursing (DON) stated V21 Registered Nurse (RN) called V2 at 8:00 AM on 5/24/25 to report that R4 had a large bruise on her Left Lower Quadrant (LLQ). V2 DON stated she reported R4's large dark purple abdominal bruise to V1 on 5/24/25. On 5/31/25 at 11:45 AM V21 Registered Nurse (RN) stated she was assisted R4 to the bathroom on the morning of 5/25/25 and noticed R4's Left Lower Quadrant (LLQ) bruise then. V21 RN stated R4's bruise was new looking and dark purple in color. V21 RN stated she completed R4's daily skin check on 5/24/25 dayshift and remembers R4 did not have any type of bruising on her abdomen at that time. V21 RN stated she heard V15 CNA had already reported R4's bruise to V16 LPN but did not know for certain so V21 reported to V2 Director of Nursing (DON) on the morning of 5/25/25. On 5/31/25 at 3:30 PM V15 Certified Nurse Aide (CNA) stated V15 first observed R4's abdominal bruise at 5:30 AM on 5/24/25. V15 CNA stated R4's bruise was 'deep, dark purple and black colored from (R4's) belly button to her Left back'. V15 CNA stated she immediately reported R4's bruise to V16 Licensed Practical Nurse (LPN) who told V2 Director of Nurses (DON). On 6/1/25 at 1:45 PM V2 DON confirmed R4's investigation of her large abdominal bruise was not thorough due to abuse was not ruled out. On 6/1/25 at 1:15 PM V1 Administrator confirmed V2 DON did not complete a thorough investigation on R4's etiology of her abdominal bruise due to not reviewing important information such as shower sheets, daily skin assessments and location of Insulin administrations. V1 Administrator stated V2 DON 145469 Page 3 of 4 145469 06/01/2025 The Haven of Paris 1011 North Main Street Paris, IL 61944

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few did not rule out abuse as a possible source of R4's bruise. V1 stated V2 DON is being educated on how to complete a thorough investigation. The facility policy titled Abuse Policy and Procedures revised 9/26/2022 documents An injury of unknown source are injuries for which both of the following conditions are met: 1. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident AND 2. The injury if suspicious because of the extent or location of the injury, the number of injuries observed at one point in time, or the incidence of injuries over time. 145469 Page 4 of 4